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CLINICAL SCIENCE
T-cell large granular lymphocytic leukemia: treatment experience with fludarabine
Renata Oliveira CostaII,,III, Marcelo BellessoI,,II,
Corresponding author
dr.marcelobellesso@gmail.com

Tel.: 55 11 3061-5544
, Dalton Alencar Fischer ChamoneI,,II, Milton Artur RuizI, Abrahão Elias Hallack NetoIV, Vera Lucia AldredV, Juliana PereiraI,,II
I Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Hematology Department, São Paulo/SP, Brazil
II Instituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo Hematology Department, São Paulo/SP, Brazil
III Lusiadas University School of Medicine, Internal Medicine Department, Santos/SP, Brazil
IV Faculdade de Medicina da Universidade Federal de Juiz de Fora, Internal Medicine Department, Juiz de Fora/MG, Brazil
V Faculdade de Medicina da Universidade de São Paulo, Pathology Department, São Paulo/SP, Brazil
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          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Peripheral blood of patient 4&#58; &#40;A&#41; at diagnosis&#44; showing T-cell receptor gamma gene monoclonal rearrangement&#59; and &#40;B&#41; after eight cycles of fludarabine&#44; showing that the monoclonal cells were completely replaced by polyclonal T-cells&#44; which is characteristic of a complete molecular response &#40;CMR&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="cesec10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle60">INTRODUCTION</span><p id="para10" class="elsevierStylePara elsevierViewall">T-cell large granular lymphocytic &#40;T-LGL&#41; leukemia is characterized by a monoclonal expansion of CD3-positive T-LGL cells&#44; as described in 1975 &#40;<a class="elsevierStyleCrossRef" href="#bib1">1</a>&#41;&#46; This rare and indolent disorder represents 2&#37; to 3&#37; of chronic lymphoid leukemia cases&#44; with a median age at diagnosis of 60 years and an equal male to female ratio &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41;&#46; The diagnostic criterion is a persistent increase in circulating monoclonal large granular lymphocytes lasting at least six months&#46; The neoplastic cells are CD3&#44; CD8 and TCR&#945;&#946; in 80&#37; of cases&#44; but they may be CD4-CD8-&#44; CD4&#43;CD8- or CD4&#43;CD8&#43; in rare variants of the disorder&#46; The associated natural killer cell antigens &#40;NKa&#41; CD16&#44; CD56 and CD57 are variably expressed&#59; CD57 is the most commonly expressed cell antigen and CD56 is the least commonly expressed cell antigen&#46; A total or partial lack of other T-cell antigens&#44; such as CD2&#44; CD5 and CD7&#44; can be observed &#40;<a class="elsevierStyleCrossRefs" href="#bib3">3&#8211;4</a>&#41;&#46;</p><p id="para20" class="elsevierStylePara elsevierViewall">T-LGL leukemia is associated with autoimmune disorders&#44; such as rheumatoid factor with or without rheumatoid arthritis&#44; Felty&#39;s syndrome&#44; Coombs-positive hemolytic anemia&#44; idiopathic thrombocytopenic purpura&#44; pure red cell aplasia&#44; the presence of positive anti-nuclear antibodies&#44; the presence of anti-neutrophil cytoplasmic antibodies&#44; hypogammaglobulinemia&#44; and polyclonal hypergammaglobulinemia&#46; Anemia and neutropenia are frequent &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41;&#46; At diagnosis&#44; 70&#37; of patients require treatment&#44; but a watch-and-wait approach may be appropriate for asymptomatic patients &#40;<a class="elsevierStyleCrossRef" href="#bib2">2</a>&#41;&#46; The most common indications for treatment are cytopenia&#44; recurrent infection and pure red cell aplasia&#44; progressive splenomegaly and B symptoms &#40;<a class="elsevierStyleCrossRef" href="#bib5">5</a>&#41;&#46;</p><p id="para30" class="elsevierStylePara elsevierViewall">There is currently no gold standard treatment for T-LGL leukemia&#46; Most patients are treated with low doses of methotrexate&#44; cyclophosphamide&#44; and cyclosporine-A&#46; As a rule&#44; the treatment should be continuously monitored and&#44; if necessary&#44; adjusted to maintain the desired response&#46; However&#44; treatment compliance is frequently low&#44; with a consequent relapse of the disease&#46; Moreover&#44; side effects are common and may limit the treatment effectiveness &#40;<a class="elsevierStyleCrossRefs" href="#bib6">6&#8211;7</a>&#41;&#46; We therefore changed our approach to treating T-LGL leukemia in an attempt to improve the hematological and molecular response rates and to reduce the treatment duration&#46; Previous studies have shown promising results with fludarabine &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#44; 2&#8242;-deoxycoformycin and alemtuzumab in T-LGL leukemia&#44; with a response rate of 40&#37; to 60&#37; when used as second-line therapy &#40;<a class="elsevierStyleCrossRef" href="#bib9">9</a>&#41;&#46; Based on our long-term&#44; positive experience with fludarabine in other hematological disorders and in view of the high cost and toxicity of alemtuzumab&#44; we changed our treatment approach to T-LGL leukemia by adopting fludarabine as the drug of choice&#46; Herein&#44; we report our experience using fludarabine in the treatment of six patients with T-LGL leukemia&#46;</p></span><span id="cesec20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle70">PATIENTS AND METHODS</span><span id="cesec30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle80">Patients and end points</span><p id="para40" class="elsevierStylePara elsevierViewall">This study was a retrospective analysis of data obtained by reviewing the medical records of six patients with T-LGL leukemia&#46; They were treated with fludarabine by the same Hematology Service of the Clinical Hospital of S&#227;o Paulo and Cancer Institute &#40;S&#227;o Paulo&#44; Brazil&#41; from January 2007 to January 2009 and February 2009 to October 2010&#44; respectively&#46;</p><p id="para50" class="elsevierStylePara elsevierViewall">The primary and secondary end points were complete hematologic &#40;CHR&#41; and complete molecular &#40;CMR&#41; response and progression-free &#40;PFS&#41; and overall survival &#40;OS&#41;&#44; respectively&#46;</p></span><span id="cesec40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle90">Diagnostic criteria for T-LGL leukemia</span><p id="para60" class="elsevierStylePara elsevierViewall">The diagnostic criterion for T-LGL leukemia was a persistent &#40;at least six months&#41; increase in circulating T-LGL cells&#44; as evaluated by cell morphology and phenotype and confirmed by a monoclonal T-cell receptor &#40;TCR&#41; gamma gene rearrangement&#46; A complete blood cell count&#44; peripheral blood &#40;PB&#41; slide examination&#44; and phenotype determination by flow cytometry were carried out using a standard multiparameter methodology to assess the antigens CD2&#44; CD3&#44; CD4&#44; CD5&#44; CD7&#44; CD8&#44; CD56&#44; CD16&#44; CD58&#44; TCR&#946;&#44; and TCR&#947;&#948;&#44; as previously described &#40;<a class="elsevierStyleCrossRef" href="#bib10">10</a>&#41;&#46; The equipment used was a FACSCalibur flow cytometer &#40;Becton Dickinson&#44; San Jose&#44; CA&#41; and the CellQuestPro software&#46; For analysis&#44; the lymphocyte region was delimitated by an electronic gate in the forward side scatter versus side scatter display&#46; Populations of T-LGL cells were defined by the co-expression of the T-cell CD3 antigen and at least one NKa CD57&#44; CD16 or CD56 antigen&#46; The normal range of T-LGL cell numbers assumed in the analysis was 0&#46;1-0&#46;3&#215;10<span class="elsevierStyleSup">9</span>&#47;L &#40;<a class="elsevierStyleCrossRef" href="#bib11">11</a>&#41;&#46;</p></span><span id="cesec50" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle100">T-cell monoclonality assessment</span><p id="para70" class="elsevierStylePara elsevierViewall">The monoclonal rearrangement of the TCR gamma gene was assessed by polymerase chain reaction &#40;PCR&#41; using primer sequences&#44; as described previously by Shadrach B and Warshawsky I &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&#46; Briefly&#44; each 25-&#181;l PCR reaction contained 200 ng of DNA&#44; 1&#46;5 U of Taq&#44; 1&#46;5 nmol&#47;L of MgCl<span class="elsevierStyleInf">2</span>&#44; 0&#46;2 nmol&#47;L of dNTP&#44; and 0&#46;5 &#181;mol&#47;L of each primer &#40;IDT Technologies&#44; Illinois&#44; USA&#41;&#46; PCR was performed in a PTC-100 DNA Engine Tetrad &#40;MJ Research&#44; Inc&#46;&#44; Waltham&#44; MA&#41; with one cycle at 94&#176;C for three min&#44; followed by 40 cycles at 95&#176;C for 60 sec&#44; 61&#46;8&#176;C for 30 sec&#44; and 72&#176;C for 30 sec&#44; with a final extension of 10 min at 72&#176;C and then held at 4&#176;C&#46; A 0&#46;1-&#181;L aliquot of the PCR product was mixed with 12 &#181;L of deionized formamide and 0&#46;5 &#181;L of GeneScan 500 HD Rox size standard &#40;Applied Biosystems&#44; Foster City&#44; CA&#41;&#46; Then&#44; the mixture was injected into an ABI Prism 3130 Genetic Analyzer&#44; and the resulting data were analyzed using the GeneMapper V 3&#46;2 software &#40;Applied Biosystems&#44; Foster City&#44; CA&#41;&#46; A monoclonality spike was determined by visual examination of the electropherograms &#40;<a class="elsevierStyleCrossRef" href="#bib12">12</a>&#41;&#46;</p></span><span id="cesec60" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle110">Treatment</span><p id="para80" class="elsevierStylePara elsevierViewall">Patients with T-LGL were treated with fludarabine if they presented with B symptoms&#44; progressive splenomegaly&#44; recurrent infection or anemia&#46; Fludarabine was used as a first-line treatment or salvage therapy&#46; HIV-positive patients were excluded from the study&#46;</p><p id="para90" class="elsevierStylePara elsevierViewall">Fludarabine was used at a dosage of 40 mg&#47;m<span class="elsevierStyleSup">2</span>&#47;day pathway oral for three to five days monthly for 6&#47;8 cycles&#46; Granulocyte colony-stimulating factor was given to all patients beginning from the 10<span class="elsevierStyleSup">th</span> day of each cycle until the end of the cycle&#44; and it was given for five days if the neutrophil count was less than 1&#46;0&#215;10<span class="elsevierStyleSup">9</span>&#47;L because it was not possible to differentiate between neutropenia secondary to the disease or due to drug toxicity&#46; Prophylaxis for <span class="elsevierStyleItalic">Pneumocystis jiroveci</span> with trimethoprim-sulfamethoxazole was also indicated for all patients&#46;</p></span><span id="cesec70" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle120">Assessment of treatment response</span><p id="para100" class="elsevierStylePara elsevierViewall">The treatment response was evaluated by periodic clinical assessments&#44; complete blood cell counts and phenotype and molecular analysis after cycles four&#44; six and eight&#46; CHR was defined as the complete normalization of blood counts &#40;i&#46;e&#46;&#44; hemoglobin &#62;120 g&#47;L&#44; platelets &#62;150&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#44; and neutrophils &#62;1&#46;5&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41; and the absence of T-LGL cells&#46; Partial hematologic response &#40;PHR&#41; was defined as an improvement of more than 50&#37; in the complete blood cell count&#46; CMR was defined as the absence of a monoclonal population as assessed by PCR &#40;<a class="elsevierStyleCrossRef" href="#bib13">13</a>&#41;&#46;</p></span></span><span id="cesec80" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle130">RESULTS</span><span id="cesec90" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle140">Clinical features</span><p id="para110" class="elsevierStylePara elsevierViewall">Five &#40;83&#46;3&#37;&#41; patients were female&#44; and the median patient age was 36&#46;5 years &#40;18 to 73&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; The median lymphocyte level was 3&#46;4&#215;10<span class="elsevierStyleSup">9</span>&#47;L &#40;0&#46;5 to 8&#46;9&#41;&#44; with a median T-LGL cell number of 2&#46;2&#215;10<span class="elsevierStyleSup">9</span>&#47;L &#40;0&#46;4-5&#46;3&#41;&#46; The median neutrophil count was 0&#46;35&#215;10<span class="elsevierStyleSup">9</span>&#47;L &#40;0&#46;2-0&#46;8&#41;&#46; Five &#40;83&#46;3&#37;&#41; patients had anemia&#44; with a median hemoglobin level of 105 g&#47;L &#40;38-143&#41;&#59; two patients &#40;33&#46;3&#37;&#41; presented with pure red cell aplasia&#44; and the disease was associated with Felt&#39;s syndrome in two patients &#40;33&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl1">Table 1</a>&#41;&#46; Four &#40;66&#46;6&#37;&#41; patients were CD3&#43;CD8&#43;TCR&#945;&#946;&#43;&#44; one &#40;16&#46;6&#37;&#41; was CD4&#43;CD8-TCR&#945;&#946;&#43;&#44; and one &#40;16&#46;6&#37;&#41; was CD4-CD8-TCR&#947;&#948;&#43;&#46; Five &#40;83&#46;3&#37;&#41; patients were CD57&#43;CD16&#43;&#44; and none of them were CD56&#43;&#46; All patients were positive for the monoclonal TCR gamma gene rearrangement&#46;</p><elsevierMultimedia ident="tbl1"></elsevierMultimedia><p id="para120" class="elsevierStylePara elsevierViewall">Two &#40;33&#46;3&#37;&#41; patients received fludarabine as first-line treatment&#44; another two &#40;33&#46;3&#37;&#41; for refractory disease&#44; one &#40;16&#46;6&#37;&#41; for relapse disease after discontinuing methotrexate treatment due to liver toxicity&#44; and one &#40;16&#46;6&#37;&#41; due to dyspesia&#46; The most common sign of toxicity was grade 4 neutropenia without infection&#46;</p><p id="para130" class="elsevierStylePara elsevierViewall">CHR was achieved in all cases&#44; and CMR was achieved in five out of the six patients &#40;83&#46;3&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig1">Figure 1</a>&#41;&#46; No case of hematological relapse occurred within a median follow-up time of 12 months&#46; All patients are still alive&#46; Bone marrow transplantation was not performed after the treatment with fludarabine because T-LGL is an indolent disease and is associated with a high rate of mortality and morbidity&#46;</p><elsevierMultimedia ident="fig1"></elsevierMultimedia></span></span><span id="cesec100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle150">DISCUSSION</span><p id="para140" class="elsevierStylePara elsevierViewall">Herein&#44; we describe our experience concerning T-LGL leukemia treatment with fludarabine&#46; We observed a high rate of CHR and CMR&#44; with good compliance and minimal side effects&#46; Because T-LGL leukemia is a rare disease&#44; prospective&#44; randomized studies to evaluate different treatment protocols are not feasible&#46; Therefore&#44; the treatment of T-LGL leukemia is based on the findings of case reports and retrospective studies &#40;<a class="elsevierStyleCrossRefs" href="#bib14">14&#8211;15</a>&#41;&#46; Thus&#44; until 2006&#44; cyclosporine and methotrexate were the only first-line therapy options for T-LGL leukemia&#46; Although effective&#44; maintenance therapy is required to achieve sustained responses with these drugs&#46; However&#44; maintenance therapy results in significant side effects&#44; especially in younger patients &#40;<a class="elsevierStyleCrossRef" href="#bib7">7</a>&#44;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#44;<a class="elsevierStyleCrossRef" href="#bib15">15</a>&#41;&#46; In fact&#44; in our institutions&#44; the median age of T-LGL leukemia patients was less than described in the literature&#46; Therefore&#44; a short time of therapy could certainly produce better results because it avoids adverse events&#46; Although indolent diseases&#44; such as T-LGL leukemia&#44; require a long follow-up period for the treatment to lead to a better overall survival&#44; our experience showed that with cyclosporine-A and methotrexate&#44; only a minority of patients were able to achieve better results&#44; due to low compliance rates and drug toxicity&#46;</p><p id="para150" class="elsevierStylePara elsevierViewall">Fludarabine has been used to treat malignant lymphoid disorders since the 1990s &#40;<a class="elsevierStyleCrossRef" href="#bib16">16</a>&#41; and has shown high efficacy in indolent diseases&#44; such as chronic lymphocyte leukemia and non-Hodgkin lymphoma&#46; In 1994&#44; Witzig et al&#46; &#40;<a class="elsevierStyleCrossRef" href="#bib17">17</a>&#41; described a case of T-LGL leukemia with transfusion-dependent anemia that was successfully treated with four cycles of fludarabine after a seven-year history of partial response to several drugs&#46; This patient became transfusion-free&#44; with a partial molecular response lasting more than 15 months&#46; Another study showed CHR in four symptomatic patients treated with fludarabine but with no CMR &#40;<a class="elsevierStyleCrossRef" href="#bib8">8</a>&#41;&#46; In another report including 26 patients &#40;<a class="elsevierStyleCrossRef" href="#bib14">14</a>&#41;&#44; 19 &#40;73&#37;&#41; were treated with different drugs&#44; either alone or in combination&#44; such as cyclosporine-A&#44; erythropoietin&#44; granulocyte colony-stimulating factor&#44; prednisone&#44; alemtuzumab&#44; pentostatin&#44; fludarabine&#44; cyclophosphamide and infliximab&#44; in addition to splenectomy and hematopoietic stem cell transplantation&#46; Cyclosporine-A was the most commonly used drug&#59; six patients achieved CHR&#44; but none of them achieved immunophenotype CR or CMR&#46; Although the authors reported an absence of response in two patients treated with fludarabine&#44; they had been previously treated at another institution and laboratory data were not available to confirm the diagnosis&#46;</p><p id="para160" class="elsevierStylePara elsevierViewall">In contrast&#44; the best results concerning CMR in T-LGL leukemia were reported in patients treated with fludarabine&#44; mitoxantrone and dexamethasone &#40;<a class="elsevierStyleCrossRef" href="#bib18">18</a>&#41;&#46; Based on this study&#44; we decided to use fludarabine to treat our T-LGL leukemia patients&#46; Our results demonstrated a high rate of CHR and CMR&#44; along with excellent treatment compliance and drug tolerance&#46; In accordance with the literature&#44; our main indication for treatment was cytopenia and recurrent infection &#40;<a class="elsevierStyleCrossRef" href="#bib19">19</a>&#41;&#46;</p><p id="para170" class="elsevierStylePara elsevierViewall">In our series of cases&#44; we found a high rate of CHR and CMR with fludarabine&#44; along with excellent compliance and tolerability&#46; Even though our number of cases was small&#44; we suggest that fludarabine should be further tested as a first-line treatment option for T-LGL to confirm these preliminary data&#46;</p></span><span id="cesec110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle160">AUTHOR CONTRIBUTIONS</span><p id="para180" class="elsevierStylePara elsevierViewall">Bellesso M and Pereira J were responsible for the data review&#44; manuscript writing and review&#46; Oliveira RC was responsible for the data collection and review&#44; manuscript writing and review&#46; Chamone DAF was responsible for the manuscript review&#46; Ruiz MA was responsible for the manuscript writing&#46; Hallack AE was responsible for the manuscript writing and review&#46; Aldred VL was responsible for the diagnosis review&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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        0 => array:2 [
          "identificador" => "xpalclavsec1582824"
          "titulo" => "KEYWORDS"
        ]
        1 => array:2 [
          "identificador" => "cesec10"
          "titulo" => "INTRODUCTION"
        ]
        2 => array:3 [
          "identificador" => "cesec20"
          "titulo" => "PATIENTS AND METHODS"
          "secciones" => array:5 [
            0 => array:2 [
              "identificador" => "cesec30"
              "titulo" => "Patients and end points"
            ]
            1 => array:2 [
              "identificador" => "cesec40"
              "titulo" => "Diagnostic criteria for T-LGL leukemia"
            ]
            2 => array:2 [
              "identificador" => "cesec50"
              "titulo" => "T-cell monoclonality assessment"
            ]
            3 => array:2 [
              "identificador" => "cesec60"
              "titulo" => "Treatment"
            ]
            4 => array:2 [
              "identificador" => "cesec70"
              "titulo" => "Assessment of treatment response"
            ]
          ]
        ]
        3 => array:3 [
          "identificador" => "cesec80"
          "titulo" => "RESULTS"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "cesec90"
              "titulo" => "Clinical features"
            ]
          ]
        ]
        4 => array:2 [
          "identificador" => "cesec100"
          "titulo" => "DISCUSSION"
        ]
        5 => array:2 [
          "identificador" => "cesec110"
          "titulo" => "AUTHOR CONTRIBUTIONS"
        ]
        6 => array:1 [
          "titulo" => "REFERENCES"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2012-03-10"
    "fechaAceptado" => "2012-03-18"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "KEYWORDS"
          "identificador" => "xpalclavsec1582824"
          "palabras" => array:3 [
            0 => "Fludarabine"
            1 => "Treatment"
            2 => "Large Granular Lymphocyte Leukemia"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "resumen" => "<span id="ceabs10" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle10">OBJECTIVES&#58;</span><p id="spara40" class="elsevierStyleSimplePara elsevierViewall">The aim of this retrospective study was to investigate the results of T-cell large granular lymphocytic leukemia treatment with fludarabine by assessing the complete hematologic response&#44; the complete molecular response&#44; progression-free survival&#44; and overall survival&#46;</p></span> <span id="ceabs20" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle20">METHODS&#58;</span><p id="spara50" class="elsevierStyleSimplePara elsevierViewall">We evaluated the records of six patients with T-cell large granular lymphocytic leukemia who were treated with fludarabine as a first-&#44; second-&#44; or third-line therapy&#44; at a dose of 40 mg&#47;m<span class="elsevierStyleSup">2</span>&#44; for three to five days per month and 6 to 8 cycles&#46;</p></span> <span id="ceabs30" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle30">RESULTS&#58;</span><p id="spara60" class="elsevierStyleSimplePara elsevierViewall">Of the six patients investigated with T-cell large granular lymphocytic leukemia who were treated with fludarabine&#44; five &#40;83&#46;3&#37;&#41; were female&#44; and their median age was 36&#46;5 years &#40;range 18 to 73&#41;&#46; The median lymphocyte level was 3&#46;4&#215;10<span class="elsevierStyleSup">9</span>&#47;L &#40;0&#46;5 to 8&#46;9&#41;&#46; All patients exhibited a monoclonal T-cell receptor gamma gene rearrangement at diagnosis&#46; Two &#40;33&#46;3&#37;&#41; patients received fludarabine as first-line treatment&#44; two &#40;33&#46;3&#37;&#41; for refractory disease&#44; one &#40;16&#46;6&#37;&#41; for relapsed disease after the suspension of methotrexate treatment due to liver toxicity&#44; and one &#40;16&#46;6&#37;&#41; due to dyspesia&#46; A complete hematologic response was achieved in all cases&#44; and a complete molecular response was achieved in five out six cases &#40;83&#46;3&#37;&#41;&#46; During a mean follow-up period of 12 months&#44; both the progression-free survival and overall survival rates were 100&#37;&#46;</p></span> <span id="ceabs40" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cestitle40">CONCLUSION&#58;</span><p id="spara70" class="elsevierStyleSimplePara elsevierViewall">T-cell large granular lymphocytic leukemia demonstrated a high rate of complete hematologic and molecular response to fludarabine&#44; with excellent compliance and tolerability rates&#46; To confirm our results in this rare disease&#44; we believe that fludarabine should be tested in clinical trials as a first-line treatment for T-cell large granular lymphocytic leukemia&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "ceabs10"
            "titulo" => "OBJECTIVES&#58;"
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          1 => array:2 [
            "identificador" => "ceabs20"
            "titulo" => "METHODS&#58;"
          ]
          2 => array:2 [
            "identificador" => "ceabs30"
            "titulo" => "RESULTS&#58;"
          ]
          3 => array:2 [
            "identificador" => "ceabs40"
            "titulo" => "CONCLUSION&#58;"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara" id="cenpara10">No potential conflict of interest was reported&#46;</p>"
      ]
    ]
    "multimedia" => array:2 [
      0 => array:7 [
        "identificador" => "fig1"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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        "descripcion" => array:1 [
          "en" => "<p id="spara10" class="elsevierStyleSimplePara elsevierViewall">Peripheral blood of patient 4&#58; &#40;A&#41; at diagnosis&#44; showing T-cell receptor gamma gene monoclonal rearrangement&#59; and &#40;B&#41; after eight cycles of fludarabine&#44; showing that the monoclonal cells were completely replaced by polyclonal T-cells&#44; which is characteristic of a complete molecular response &#40;CMR&#41;&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "tbl1"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spara30" class="elsevierStyleSimplePara elsevierViewall">F &#61; Female&#59; M &#61; Male&#59; PRCA &#61; pure red cell aplasia&#46;</p>"
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                  \t\t\t\t  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Age&#47;gender&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Presentation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Hemoglobin &#40;g&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Lymphocytes &#40;x 10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Neutrophils &#40;x 10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Platelets&#40;x 10<span class="elsevierStyleSup">9</span>&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">54&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Felty&#39;s syndrome&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">143&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">1&#46;8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">147&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">45&#47;M&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Infection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">117&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">3&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">319&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">73&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Felty&#39;s syndrome&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">129&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="center" valign="top">245&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="center" valign="top">25&#47;F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">Infection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">105&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">8&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="center" valign="top">0&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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